Childbirth - The Right to Choose

In January 2017 a Coroner in Tunbridge Wells heavily criticised a local Hospital for pressurising Mrs Frances Cappuccini to try for a natural delivery rather than a planned elective caesarean section.

This decision led to a tragic series of further medical mistakes resulting in Mrs Cappuccini’s death. The NHS’ apparent preference for natural births has rightly been called into question as a result.

A woman has the right to choose what type of childbirth she has. Caesarean sections are usually performed if a natural vaginal delivery is deemed too risky. Elective caesarean sections are planned, in advance of the labour, based on an assessment of the medical risks and/or a women’s preference.

Mrs Cappuccini, for example, had arranged for an elective caesarean section with her obstetrician in the antenatal period because of a difficult first pregnancy involving a placental tear. She was “terrified” of a natural birth because of this experience and her obstetrician rightly took her views into account in his advice. Sadly, this sensible plan was overruled by the midwife at the last minute.

Why does the NHS favour natural births? What are the main risks with each type of delivery.

Natural Births

Natural vaginal births account for 75% of all childbirths in the country. We are told that they are the safest form of delivery and are better for the baby and also the fertility of the mother. They avoid the need for operative surgery (and the associated surgical risks) as opposed to a caesarean section which should allow the mother to be in close contact with her baby earlier/leave Hospital sooner.

It is thought that natural births also reduce a baby’s immediate breathing problems because they receive a dose of good bacteria when passing through the birth canal which can boost their immune system. If the delivery proceeds well the baby is also thought to be less at risk and less stressed.

From the other perspective, if the natural birth is prolonged and there are difficulties the baby can suffer very serious injuries such as oxygen starvation which can cause cerebral palsy. If the baby becomes stuck an urgent assisted delivery (forceps or ventouse) may be required raising the risks of injury to the baby (shoulder distocia, bruising and scarring) and mother. If the baby remains stuck an emergency caesarean section may be required involving moving the baby back out of the birth canal before delivery. Infection, obtained from the mother’s birth canal, is also another risk factor.

From the mother’s point of view, vaginal births can be physically and mentally gruelling. Tears and stretches can occur when the baby passes through the birth canal which can cause injury to the pelvic muscles impacting on future urine and bowel control. Repair stitching may be required. A mother may also suffer long term pain in her perineum as a result of a natural birth.

Caesarean Sections

Caesarean sections account for the minority of childbirths. As a surgical procedure, elective caesarean sections are booked in advance with a team of doctors so that the birth-date is planned.

They avoid the need for a potentially prolonged and painful natural birth. This often provides much needed reassurance to a mother about childbirth and the difficulties and risks associated with this.

The direct benefits of a caesarean section to the mother and baby are limited. The key benefit is avoiding the chance of serious natural birth complications. The risks are, however, quite extensive.

Surgery carries an automatic increase in risk of blood loss, infection, blood clots and injury to internal organs. The standard of surgery is usually very high but risks increase when a rapid emergency rather than elective caesarean section takes place. Mrs Cappuccini, for example, suffered a major bleed because her placenta was not properly removed during her emergency caesarean section. Caesarean sections usually mean a mother remains in Hospital longer (2-4 days on average), has less immediate contact with her baby and longer lasting pain over the incision site.

From the baby’s perspective, research indicates caesarean sections increase the risk of breathing problems, stillbirth, asthma and even obesity - although the research for this remains limited. There is also the risk of a direct cutting injury to the baby during the surgical procedure itself. The long term health implications for a baby of being delivered by caesarean section remain uncertain.

Advice

The Royal College of Obstetricians and Gynaecologists have provided a Guidance leaflet about the benefits and risks of caesarean sections which can be found here. They rightly note that most women in the UK give birth naturally without complication but advice about the benefits of an alternative caesarean section should be fully discussed with them by their midwife or doctor.

Comment

The general perception seems to be that a natural child birth rewards a mother with a sense of achievement and potentially greater early connection with her baby than a caesarean section. It goes without saying, however, that caesarean sections have enabled mothers with medical or non-medical concerns to deliver healthy children. Cost, alongside these general views, is also likely to be a factor in the views expressed by the NHS on this issue. It is thought that, on average, a caesarean section costs the NHS more than double the cost of a natural birth. This may be one of the reasons why Mrs Cappuccini’s midwife overruled her decision to have an elective caesarean section.

Ultimately the type of delivery a mother chooses should be based on full and reasoned medical advice and detailed information about the short and long term benefits and risks of both. Personal preferences from medical staff should be offered as advice rather than dictating a mother’s choice.

Click here for Charles Gillott’s blog for the legal position on a patient’s right to choose. [add link]

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